Strategies to help patients lose weight and become active after surgery need to be individualized, multifaceted, and reinforced long-term.
By Keith Loria
Many people who suffer from chronic joint pain are unable to exercise; as a result of this inactivity, they gain weight, which only increases their joint pain. To end this cycle, therefore, it only makes sense that having surgery to relieve that pain will help patients be more active and lose weight.
Surprisingly, this does not happen as often as one would think: Even after surgery, many patients choose not to exercise. That leads to an increased risk of implant failure or development of pain in other joints than if they had been able to decrease their body mass index (BMI) after the initial surgery.
Webb A. Smith, PhD, clinical exercise physiologist at Le Bonheur Children’s Hospital, Memphis, TN, noted that, after recovery from surgery, pain is generally reduced but behaviors and habits present before surgery largely persist. Although there are exceptions to this phenomenon, on average, patients end up with less pain but the same sedentary behaviors and habits.
“Being obese increases risk of developing and progression of osteoarthritis,” Smith said. “The trouble is that many of the factors that lead to obesity—Western diets, sedentary behaviors, and low amounts of physical activity—are also problematic with respect to osteoarthritis. This makes the treatments for obesity and osteoarthritis very similar with respect to lifestyle and behavioral change.”
In addition, although patients identify joint pain and reduction in activity as reasons for weight gain, the causality of this relationship has been difficult to evaluate because most patients are already obese at presentation of joint pain and most don’t lose weight after.
Christine Pellegrini, PhD, assistant professor of exercise science at the University of South Carolina’s Arnold School of Public Health, said behavior change is difficult: Before surgery, many patients are inactive because of pain and physical limitations.
“Patients are likely to try multiple different treatment options before turning to surgery, which means that this pattern of inactivity could be happening for many years,” she said. “After the surgery, patients are likely to have better function and less pain but, because they’ve spent many years being inactive, it’s hard to quickly switch back to a more active lifestyle.”
James R. Hanna, DPM, of the New York State Podiatric Medical Association, said many people are “creatures of habit,” and that an intervention such as surgery that alleviates pain merely allows them to go back to the lifestyle to which they’re accustomed—often, lifestyle habits that led to chronic pain in the first place.
“An inability to manage BMI after surgery certainly increases the risk for implant failure and progression of degenerative joint disease,” Hanna said. “Other challenges to a person’s health from an elevated BMI are manifold. These include the development of type 2 diabetes mellitus, cardiovascular disease (often complicated by hyperlipidemia associated with elevated BMI), and hypertension.”
Fear of re-injury can, of course, be a roadblock to assuming a more active lifestyle, but Hanna believes that proper education by the physician or surgeon, as well as comprehensive physical therapy, can help ease the post-surgical transition and allay these fears. Group exercise, bringing together patients who are at in a similar point in their recovery, can be useful as well.
Mary E. Sanders, PhD, ACSM-RCEP, CDE, FACSM, clinical exercise physiologist and adjunct professor at the School of Community Health Sciences, University of Nevada, Reno, noted obesity and poor health increases the risk of any surgical procedure, and her clinic requires that patients attend a special “boot camp” before the agree to undergo a procedure.
“Bariatric surgery is complicated, expensive, and people need to qualify,” she said. “Bariatric patients had to complete a 12-week weight loss, behavior change program to demonstrate their ability to lose weight (5% or more) and increase physical activity and control their diet in line with what their new eating pattern will be post-surgery in order to qualify for surgery.”
Challenges of losing weight
Post-surgically, obese and inactive patients often have a higher risk of implant failure and pain in other joints than if they had been able to decrease their BMI right after surgery—just one of the many challenges that result from this. Some research has suggested that patients who are obese may also have poorer functional outcomes after undergoing knee replacement.
When patients have surgery, they typically attend physical therapy, which focuses on increasing range on motion and strength, mostly in the leg that was surgically repaired. Smith said the recovery period after surgery is marked by a high amount of sedentary time, which is necessary to protect the repaired area and allow recover from surgery. However, this leads to deconditioning of the whole body and, possibly, strength imbalances.
“The surgically repaired leg is treated in physical therapy while the rest of the body may not be challenged to the same degree,” Smith said. “Patients may feel better and pain free but, without a treatment plan, this can mean that more pressure is placed on the rest of the body that was not repaired. This leads to frustration with treatment and may be discouraging.”
Not surprisingly, this situation reduces the patient’s commitment to future physical therapy intervention and exercise in general.
The weight loss program at Pellegrini’s facility, modeled after evidence-based programs and modified based on patient input, includes numerous behavioral strategies to help patients modify their diet and physical activity.
“We included regular calls, either weekly or every other week, to set goals and problem-solve around barriers patients were experiencing,” Pellegrini said. “Participants were en- couraged to track their diet, physical activity, and weight loss throughout the program, using paper diaries, a website, or activity monitor like Fitbit. We provided educational materials that discussed topics like how to eat fewer calories, how to be more active, and how to prevent a relapse. We also sent patients text messages three times a week to provide encouragement, tips, and reminders.”
Three studies offer insights on overcoming barriers to weight loss
Most research shows that the primary barriers to activity include pain, physical limitations such as loss of range of motion, stiffness, and fatigue, and a lack of motivation. It is likely that some of the pain and physical limitations would decrease over time, but patients may still experience a lack of motivation to exercise, similar to the rest of the population.
Assessing physical function and activity in obese patients after total knee arthroplasty. Webb A. Smith was lead author on a study of physical function and activity in obese subjects who had undergone total knee arthroplasty, focusing on their abilities and quality of life after having completed standard medical treatments and were released to resume normal activities.1 The study evaluated patients one year after knee replacement and put them through a physical fitness assessment that measured parameters such as muscle strength, walking endurance, and range of motion in the knee. Researchers also asked study participants about their perceptions of knee pain, function, stiffness, and health-related quality of life.
“We found that pain had improved in most patients but they were still highly sedentary with no patients reaching recommended levels of physical activity,” Smith said. “We also found that, compared to the population of people their age, that most had physical fitness deficits. My key take-away from this was the patients were not able to do the same activities as their peers and were missing an opportunity to improve these deficits with exercise. By not taking advantage of the exercise, they were not getting the most out the surgery and were not recovering to their fullest potential.”
Importance of podiatric services. Podiatry is a key component to improving the quality of life for obese patients. The New York State Podiatric Medical Association contracted with Navigant Consulting to quantify the value of podiatric services in helping reach New York healthcare goals.2 Results of this analysis demonstrate a decrease in hospitalizations and lower healthcare costs for obese people who saw a podiatrist, compared to those who did not receive podiatric intervention.
The analysis revealed a 19% reduction in the odds of a subsequent inpatient admission among obese persons receiving services provided by a podiatrist, and a possible savings opportunity as high as $1.1 billion in healthcare costs through reduced hospitalizations and other costs of care.
The results showed that inclusion of comprehensive podiatric services in value based payment arrangements results in reduced obesity-related hospitalizations and lower healthcare costs.
Patients’ preferences for weight-loss strategies. Christine Pellegrini led a study looking to 1) identify knee-replacement patients’ preferences for weight-loss programs and 2) qualitatively understand previous motives for weight-loss attempts and strategies used to facilitate behavior change.3
“We’ve held qualitative interviews with patients, either before or after surgery, to identify their barriers to healthy eating and physical activity,” Pellegrini said. “We also asked patients about their preferences for a weight-loss program. Using those results, we developed a weight-loss program for knee-replacement patients, and we just completed a trial comparing weight-loss outcomes between patients who started a weight-loss program up to six weeks before surgery or 12 weeks after surgery.”
The 20 patients (11 preoperative, 9 postoperative, between 47 and 79 years) who completed the study reported a preference for a weight loss program that starts before surgery, is of at least 6 months’ duration, and focuses on both diet and exercise.
However, even though most of the patients interviewed before the study began said that they would prefer to start a weight loss program before surgery, findings were that patients may be able to achieve a greater weight loss if they wait to start the program after knee replacement.
“We found that patients who started the weight-loss program 12 weeks after knee replacement lost significantly more weight than those who started up to six weeks before surgery,” Pellegrini said. “Patients who started before surgery lost approximately 8% of their body weight at 26 weeks after surgery, whereas those who started the program before undergoing knee replacement only lost about 2.5% of their body weight.”
Potential solutions to this problem
In the US, more than two-thirds of adults are considered overweight or obese, and many are concerned that these numbers will continue to rise.
“A comprehensive approach needs to be taken to address this problem,” James R. Hanna said. “Education of all children with respect to healthy lifestyle and dietary habits is crucial. Encouraging primary care physicians to utilize registered dietitians and exercise programs could be very helpful. In tandem with this is the need for insurance programs to recognize the need for this type of preventative care and education.”
Some of the better potential ways to address the problem include:
- better education about the benefits of exercise and weight loss
- group exercise programs
- setting realistic goals
- automated reminders.
Although all these strategies help, Mary E. Sanders said they have to be individualized, with follow-up supervision, for any to succeed. People with diabetes, for example, can make positive changes in blood glucose control with at least 5% weight loss.
“Assistive devices and appropriate exercises (cycling, Nordic walking, water exercise) can build confidence in movement that can progress to more physical activity,” Sanders said. “Compression gear, taping, and other external assistance can help reduce symptoms [and provide] a comfortable experience.”
Braces, gait assistive devices, and other rehabilitation equipment can be useful in transitioning to activity following surgery, Hanna noted. Monitored exercise by a physical therapist or athletic trainer to help guide the patient can also be useful in preventing re-injury and easing this transition.
“Although not very common for a variety of reasons, I would advocate for a whole-body fitness plan tailored to the pain and deficits once patients are medically cleared to improve overall strength and fitness,” Smith said.
For patients recovering from foot and ankle surgery, Smith recommends comfortable, stable athletic shoes—and replacing them regularly.
“They don’t need to be fancy or expensive, but should be changed every few months, depending on how active, since cushioning wears out and puts more pressure on the legs,” he said. “Many patients had sore feet and legs from walking with really old athletic shoes or nonathletic shoes. Loafers may be stylish and comfortable for shuffling around but they are not an athletic shoe designed to absorb the pounding from an exercise session.”
Keith Loria is a freelance medical writer.
- Smith WA, Zucker-Levin A, Mihalko WM, et al. Physical function and physical activity in obese adults after total knee arthroplasty. Orthop Clin North Am. 2017;48(2):117-125.
- New York State Podiatric Medical Association (NYSPMA). New York State Podiatric Medical Association study shows podiatry decreases diabetic hospitalizations and healthcare costs. November 17, 2017. Available at: http://www.nyspma.org/aws/NYSPMA/pt/sd/news_article/147710/_self/layout_details/false. Accessed: January 23, 2017.
- Pellegrini CA, Ledford G, Hoffman SA, et al. Preferences and motivation for weight loss among knee replacement patients: implications for a patient-centered weight loss intervention BMC Musculoskelet Disord. 2017;18(1):327.